A pilot project on coordination between two levels of care: heart failure unit and programme for prevention and support on discharge (PiSA-IC)/Una experiencia de coordinación entre dos niveles asistenciales: Unidad de Insuficiencia Cardiaca—Programa de prevención y soporte al Alta (PiSA-IC)

Heart failure (HF) is the third cause of cardiovascular death in Spain, after ischaemic heart disease and cerebrovascular disease [1]. As in other developed countries, HF is the leading cause of hospitalisation of people over 65 years of age and accounts for more than 5% of hospital stays, this corresponding to 70% of the costs associated with HF syndrome [2]. Moreover, the number of admissions due to this condition has increased in recent years in Spain. This is attributable to an increase in the prevalence of the diseases due to population ageing [3]. HF-related healthcare accounts for 2% of the total healthcare budget [2], without taking into account the personal costs of the disease in terms of patient quality of life and early death.


Introduction
Heart failure (HF) is the third cause of cardiovascular death in Spain, after ischaemic heart disease and cerebrovascular disease [1]. As in other developed countries, HF is the leading cause of hospitalisation of people over 65 years of age and accounts for more than 5% of hospital stays, this corresponding to 70% of the costs associated with HF syndrome [2]. Moreover, the number of admissions due to this condition has increased in recent years in Spain. This is attributable to an increase in the prevalence of the diseases due to population ageing [3]. HF-related healthcare accounts for 2% of the total healthcare budget [2], without taking into account the personal costs of the disease in terms of patient quality of life and early death.
It is important to clinically monitor such patients, since a relatively large number of clinical worsening events can be avoided with a series of checkups, these having demonstrated their usefulness in decreasing recurrent hospital admissions [4]. In recent years, the action strategies for HF syndrome have changed, mainly in primary care; the great difference is a change in approach due to acceptance that HF is not only an acute disease (as treated to date in hospital settings), but also a chronic clinical syndrome that should be diagnosed early and monitored, with an emphasis on the need for prevention. It has been demonstrated that a multidisciplinary approach across various levels of care and systematic programmes improve patient quality of life and satisfaction as well as decreasing the number of hospital admissions [5].
In our region, with the aim of improving healthcare for this type of patient, we opted for centralising services around the core provider, the Heart Failure Unit-which is hospital based-and at the same time establish a programme for prevention and support on discharge (PiSA), shared with primary care, reaching out to patients in their environment. In the Heart Failure Unit, patients receive multidisciplinary medical and nursing care: they are diagnosed, assessed and treated progressively, according to the course of their condition. At the same time, we initiate and develop their specialised healthcare education. This activity is continued when the patient returns home through the care provided by the case manager of the PiSA programme. These nurses who have received special training are members of the primary and specialised care teams and also know about the patients' home environments. We carried out a study in order to describe the characteristics of the pilot project on coordination between these two levels of care and to assess the results.

Methods
This was a descriptive cross-sectional study carried out between June 2006 and May 2009. A total of 208 patients diagnosed with HF were included. The inclusion criteria were: being diagnosed with HF NYHA functional class II, III or IV, independent or dependent with family support, and resident in one of seven basic health areas (geographical zones for the administration of healthcare) in the catchment area of the hospital. Patients with significant cognitive impairment were excluded. Demographic and clinical variables were analysed as well as attendances to the emergency department and hospital admissions.
During hospitalisation, patients were recruited to the programme and then an agreement was reached with regards to their future monitoring through outpatient appointments with the specialist consultant and the hospital clinical nurse. On discharge, patients continued to receive education and their progress was monitored in their own home by the primary care nurse case manager. Communication between the hospital and primary care was maintained using the information technology systems of the Catalan Institute of Health (public provider of healthcare in Catalonia) and by telephone. In addition, patients and relatives were able to contact the PiSA team on a designated telephone number. The intervention carried out in these patients is described in detail in the Heart Failure Unit clinical guidelines. A computer programme was developed for the registration and follow-up of patients as well as recording of the study data.
The centres in the basic health areas of the catchment area of the hospital have patient referral forms to establish a diagnosis, seek advice on management and request further tests (e.g., an ECG).

Results
The study population had an average age of 65 years and 60% were men. A total of 40.7% of the patients had NYHA functional class III and their mean ejection fraction was 33%. The most common aetiology was ischaemic heart disease (43.7%), followed by hypertensive heart disease (23.2%). During the study period, the number of attendances to the emergency department decreased by 67% (mean number of attendances in the pre-intervention period: 1±0.084 vs. in the intervention period 0.33±0.06, p<0.001). Further, hospital admissions were reduced by 60.27% (1.4±0.114 vs. 0.56±0.104, p<0.001) and the mean length of hospital stay of patients admitted for HF fell by 60.84% (8.79±0.71 vs. 3.46±0.658 days, p<0.001).

Conclusions
In our experience, for patients with chronic heart failure, a health care model based on coordination between two levels of health care, ensures consistency in treatment and patient education and improves follow-up, strengthening self-management of the condition. In our region, this type of intervention considerably reduced the number of attendances to emergency departments, hospital admissions and mean length of hospital stays. Early intervention on discharge by the multidisciplinary team across the levels of care means that patients learn about their own condition, recognise when there is clinical worsening and inform the PiSA team, all of this decreasing the overall amount of hospital care required.